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--- --- .••rte==r .,�mN�C�Ca. og oure io aign me Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH "PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictionalarea Of San aquin Local_Health District <br /> Business Name (DBA) .�La{>�� Address <br /> cOwner Address ' <br /> J Firm Partners, Addresses and Telephone NumbersCL <br /> CL <br /> k-1Business Telephone No.. 4,6:,C-_->—SGgz) Emergency Telephone No. <br /> Contractor Licence No. 7� _L��,' <br /> L Applicants Name (Print) `/ Title: CiG_—Q Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19L y <br /> Disposal'Sites-. <br /> Description(Make/Yr., Color) <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> Capacity '_ _ Gal., Weights& Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ' <br /> Te sE cation Test Date/Time <br /> 4. SANITATION PERMIT ti <br /> Job Address/Location it 01P6L4___N, gVQC�_ � J <br /> O ner Me . £ LE2'T' Address <br /> 3� <br /> SEPTIC TANK Cl CESSPOOL C1 LEACHING FIELD C1 SEEPAGE PIT El PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site ' <br /> No. of Units Equipment Storage/Cleaning Location(s)'- ` <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 - <br /> Operator Name Where Certified <br /> Plant Location '! ; <br /> Plant Capacity No. Units Served '0 + <br /> 7. Cl LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq. Ft: ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. % - <br /> i --ueh���t t r �'ssl�rB�tiF�'Z�`7fi�s'thA!k3f►uovT�g'� ;�'Fh'1t�t� 'D'fgh -_���Hyy_ _ <br /> �` � ��t)b�Nf�Plctf7f afl'S C In j" .. I(::. �er4'011fT�ry0e IlrffrlQftfUfSl4�IfiG41 .�Q�1l1� m71 <br /> 9 Ct50 rfit?F �1 i �I �;7sit 0 I��t1•'�n•r�..�ni,.:tt:`nitt E If�1K.!(��R7�S <br /> i:. Y a$S.�Q�t��{!'1;1'�1'�.�T�-�i�! si nbr G'� a~n'=fiTfna `j;•,. .':.rlrr..n, '�wi:�.ii�'•.:FiS:IR ttl <br /> n?ttiGl;:tT ,i:��i:tue,:,.4•,,,=w.' " e perfnrmartce of lire wa>Vcttorwtliitt�iNtts4Ritifs�Sgii�4l.d ?IE <br /> I hereby certify that I ha�r41prepared this application an hat the work will be done in accordance with San Joaquin County r° n <br /> ordinances, state laws, ules and r ations of the n JoAin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE - REMITTED AMOUNT DUE CHECKED <br /> _AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> G .r <br /> OTHER <br /> OTHER r <br /> Received by Date Receipt No. Permit No. Issuancb Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sam 2009 STOCKTON,CA 95201 <br />